Methods of treating dementia by administering virus-like particles coupled to Aβ

ABSTRACT

The present invention relates to novel uses of a construct consisting of virus-like particle (VLP) structure chemically coupled to a fragment of the Aβ-1-42 peptide and its pharmaceutically acceptable salts (hereinafter CONSTRUCT), in particular to dosage regimens, modes of and dosage forms for the administration of a CONSTRUCT for the treatment of patients suffering from dementia, in particular dementia of the Alzheimer&#39;s type.

The present invention relates to novel uses of a construct consisting ofvirus-like particle (VLP) structure chemically coupled to a fragment ofthe Aβ-1-42 peptide and its pharmaceutically acceptable salts(hereinafter CONSTRUCT), in particular to dosage regimens, modes of anddosage forms for the administration of a CONSTRUCT for the treatment ofpatients suffering from dementia, in particular dementia of theAlzheimer's type, especially mild to moderate or severe Alzheimer'sDisease (AD), and vascular dementia with amyloid angiopathy to a methodof isolating immune cells, especially antibody producing cells, andantibodies as well as there genes or fragments thereof generated by theimmune system of a warm-blooded animal, especially a human, in responseto the administration of the CONSTRUCT, the production of suchantibodies and the pharmaceutical use of such antibodies.

The present invention relates to novel uses of a construct consisting ofvirus-like particle (VLP) structure chemically coupled to a fragment ofthe Aβ-1-42 peptide and its pharmaceutically acceptable salts(hereinafter CONSTRUCT), in particular to dosage regimens, modes of anddosage forms for the administration of a CONSTRUCT for the treatment ofpatients with increased Aβ-level, including but not limited to patientswith dementia associated with Parkinson's disease, Lewy Body dementia.

The present invention also relates to novel uses of a constructconsisting of virus-like particle (VLP) structure chemically coupled toa fragment of the Aβ-1-42 peptide and its pharmaceutically acceptablesalts (hereinafter CONSTRUCT), in particular to dosage regimens, modesof and dosage forms for the administration of a CONSTRUCT for theprophylactic treatment of subjects at risk of developing AD, includingbut not limited to subjects with mild cognitive impairment , subjectswith genotypes known to be associated with AD, such as ApoE4, subjectswith Trisomy 21 and subjects with surrogate markers indicating risk forAD.

Considerable evidence has been accumulated suggesting that the β-amyloidpeptide—the major component of senile amyloid plaques - plays a causalrole in AD. Successful disease-modifying therapy for AD is likely toinclude products that affect the deposition of β-amyloid in the brain.Aβ-specific antibodies, actively generated by the immune system orpassively administered, consistently reduce plaque burden in differenttransgenic mouse models for Aβ-amyloidosis. A first clinical attempt tostimulate the immune system of AD patients to generate Aβ-antibody,however, had to be suspended due to unacceptable side effects(meningoencephalitis in 6% of treated patients, Orgogozo J M, Gilman S,Dartigues J F, Laurent B, Puel M, Kirby L C, Jouanny P, Dubois B, EisnerL, Flitman S, Michel B F, Boada M, Frank F, Hock C (2003)] Subacutemeningoencephalitis in a subset of patients with AD after Aβ42immunization. Neurology; 61: 46-54.).

Surprisingly, lesser adverse immune reactions and a lesser incidence ofmicrohemorrhages are observed with the CONSTRUCTS disclosed herein. Inparticular, no adverse immune reaction nor increased incidence ofmicrohemorrhages, is observed with CONSTRUCTS consisting of a VLPchemically coupled to the Aβ-1-6 peptide.

In a first aspect of the present invention, it was surprisingly foundthat the CONSTRUCT advantageously can be applied subcutaneously towarm-blooded animals, especially humans, suffering from dementia.

In another aspect of the present invention, it was surprisingly foundthat the CONSTRUCT advantageously can be applied intramuscularly,intranasally and orally to warm-blooded animals, especially humans,suffering from dementia.

In a second aspect, the present invention provides a dosage form forsubcutaneous administration of the CONSTRUCT. The preferred dosage formfor subcutaneous administration of the CONSTRUCT is an aqueous solutioncontaining Phosphate Buffer Saline (PBS), between 0.25 and 0.75 mg/mLCONSTRUCT, preferably between 0.4 and 0.6 mg/mL, e.g. 0.5 mg/mLCONSTRUCT, and no further excipients. The dosage form can be kept frozenuntil shortly before usage. The dosage form is administered preferablyby subcutaneous injection with a syringe to the warm-blooded animal,especially into the abdomen. For thawing of the dosage form, the dosageform can be kept at ambient temperature for about between 15 minutes and45 minutes, e.g. 30 minutes. Preferably, before withdrawing drugsubstance, the vials are gently inverted several times for dispersion ofpotential sub-visual particles.

The CONSTRUCTS as employed in the present invention are known as such.For example, WO 00/3227 to Cytos discloses a technology for providing aconstruct comprising a core-particle (such as a VLP), a linker and anantigen, all together forming an ordered and repetitive antigen array.WO 02/056907 to Cytos and Novartis describes constructs comprising a VLPcomprising recombinant proteins of a bacteriophage, such as Qβ, a linkerand an antigen, e.g. Aβ1-42 or a fragment thereof, all together formingan ordered and repetitive antigen array. Preferably, a CONSTRUCT as usedherein consists of capsid proteins of a RNA bacteriophage, morepreferably of capsid proteins of the RNA bacterio-phage Qβ,self-assembled into a highly ordered VLP structure chemically coupledwith a bivalent linker to a fragment of the Aβ1-42 peptide, morepreferably to Aβ-1-6. The CONSTRUCT can be prepared, purified andadministered as disclosed in WO 00/3227, WO 02/056907 or WO2004/016282,especially in Example 13, which patent filings as well as the referencescited therein are incorporated by reference into the present patentapplication, especially the end products of the Examples.

The term “treatment” as used herein relates in particular to a treatmentaiming to halt pathogenic processes that lead to disease progressionand/or has symptomatic effects.

The term “prophylactic treatment” as used herein relates in particularto a treatment aiming to halt pathogenic processes leading to disease.

The term “dementia of the Alzheimer's type” as used herein relates inparticular to a disease as defined according to the Diagnostic andStatistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria.

In a third aspect, the present invention relates to a method oftreatment of dementia in human patients comprising administering 5 to175 μg, preferably 15 to 125 μg, more preferably about 25 to 100 μg,e.g. 50 μg or 75 μg, of the CONSTRUCT to human patients in need thereofabout every 4 to 8 weeks, preferably about every 5 to 7 weeks, inparticular about every 6 weeks.

In a fourth aspect the present invention relates to a method oftreatment of dementia in human patients comprising administering 5 to1000 μg, preferably 5 to 300 μg, more preferably about 50 to 200, mostpreferably 50-150 μg, e.g. 50 μg or 75 μg, 100 μg, 125 μg, 150 μg of theCONSTRUCT to human patients in need thereof about every 4 to 8 weeks,preferably about every 5 to 7 weeks, in particular about every 6 weeks.Frequency of injection can vary depending on the patient response.

For example the frequency of administration can vary if the injectionhas to be administered according to antibody titers.

The usefulness of the CONSTRUCTS in the treatment of the above-mentioneddisorders can be confirmed in suitable clinical studies, e.g. thosedescribed in the Examples, e.g. applying a total daily dosage of 25 to100 μg CONSTRUCT to patients every 4 to 8 weeks.

Suitable clinical studies are in particular randomized, double-blind,placebo-controlled, parallel studies in Alzheimer's patients or openlabel studies.

In a further aspect, the present invention pertains to a combinationcomprising at least one CONSTRUCT and at least one nootropic agent,preferably one cholinesterase-inhibitor, or memantine.

The term “nootropic agent” as used herein includes, but is not limitedto nootropic plant extracts, calcium antagonists, cholinesteraseinhibitors, dihydroergotoxin, nicergoline, piracetame, purine derivates,pyritinol, vincamine and vinpocetine.

The term “nootropic plant extracts” as used herein includes, but is notlimited to extracts from Ginkgo leafs. The term “calcium antagonists” asused herein includes, but is not limited to cinnarizine and nimodipine.The term “cholinesterase inhibitors” as used herein includes, but is notlimited to donepezil hydrochloride, rivastigmine and galantaminehydrobromide. The term “purine derivates” as used herein includes, butis not limited to pentifyllin.

Extracts from Ginkgo leafs can be administered, e.g., in the form asmarketed, e.g. under the trademark Ginkodilat™ according to theinformation provided by the package insert. Cinnarizine can beadministered, e.g., in the form as marketed, e.g. under the trademarkCinnarizin forte-ratiopharm™. Nimodipine can be administered, e.g., inthe form as marketed, e.g. under the trademark Nimotop™. Donepezilhydrochloride can be administered, e.g., in the form as marketed, e.g.under the trademark Aricept™. Rivastigmine can be prepared as disclosedin U.S. Pat. No. 5,602,176. It can be administered, e.g., in the form asmarketed, e.g. under the trademark Exelon™. Galantamine hydrobromide canbe administered, e.g., in the form as marketed, e.g. under the trademarkReminyl™. Dihydroergotoxin can be administered, e.g., in the form asmarketed, e.g. under the trademark Hydergin™. Nicergoline can beadministered, e.g., in the form as marketed, e.g. under the trademarkSermion™. Piracetam can be administered, e.g., in the form as marketed,e.g. under the trademark Cerebroforte™. Pentifyllin can be administered,e.g., in the form as marketed, e.g. under the trademark Cosaldon™.Pyritinol can be administered, e.g., in the form as marketed, e.g. underthe trademark Encephabol™. Vinpocetin can be administered, e.g., in theform as marketed, e.g. under the trademark Cavinton™. Memantine can beadministered, e.g., in the form as marketed, e.g. under the trademarksAxura™ or Namenda™.

The structure of the active agents identified by code nos., generic ortrade names may be taken from the actual edition of the standardcompendium “The Merck Index” or from databases, e.g. PatentsInternational (e.g. IMS World Publications). The corresponding contentthereof is hereby incorporated by reference.

Hence, the present invention pertains also to a combination comprising aCONSTRUCT of the invention, and at least one nootropic agent selectedfrom the group consisting of nootropic plant extracts, calciumantagonists, cholinesterase inhibitors, dihydroergotoxin, nicergoline,piracetame, purine derivates, pyritinol, vincamine and vinpocetine ormemantine, in which the active ingredients are present in each case infree form or in the form of a pharmaceutically acceptable salt andoptionally at least one pharmaceutically acceptable carrier, forsimultaneous, separate or sequential use, especially for use in a methodof treating dementia.

Such a combination is preferably a combined preparation.

Other agents can be used in combination with the CONSTRUCT, for example:antidepressants such as SSRIS, SNRIs, NRIs, antipsychotics such asrisperidone, antidiabetic treatments such as insulin or mefformin,antioxidative treatments such as selegiline, vitamin E,anti-inflammatory treatments such as NSAIDs, lipid-lowering agents suchas statins, hormone substitution such as estrogens, amyloid loweringagents such as abeta secretase inhibitors, aggregation inhibitors suchas beta-sheet blockers, chelators, immunomodulatory agents such asglatiramer acetate.

The term “a combined preparation”, as used herein defines especially a“kit of parts” in the sense that the active ingredients as defined abovecan be dosed independently or by use of different fixed combinationswith distinguished amounts of the ingredients, i.e., simultaneously orat different time points. The parts of the kit can then, e.g., beadministered simultaneously or chronologically staggered, that is atdifferent time points and with equal or different time intervals for anypart of the kit of parts. Preferably, the time intervals are chosen suchthat the effect on the treated disease in the combined use of the partsis larger than the effect which would be obtained by use of only any oneof the active ingredients.

Hence, the present invention also provides

-   -   the use of a combination as disclosed herein for the preparation        of a medicament for the treatment of dementia, in particular        Alzheimer's disease; and    -   a commercial package comprising a combination as disclosed        herein together with instructions for simultaneous, separate or        sequential use thereof in the treatment of dementia, in        particular Alzheimer's disease.

In one preferred embodiment of the invention, the combination partner(b) is a cholinesterase inhibitor, especially rivastigmine, ormemantine.

If the combination partners are administered as separate dosing forms, adosage and mode of administration can be applied as provided in thepackage inserts. In particular, the following dosages of the combinationpartners (b) can be administered to the patient:

Cinnarizine may be administered to a patient in a total daily dosage ofbetween about 75 to about 150 mg.

Nimodipine may be administered to a patient in a total daily dosage ofbetween about 60 to about 120 mg.

Donepezil hydrochloride may be administered to a patient in a totaldaily dosage of between about 5 mg and 10 mg.

Rivastigmine may be administered to a patient in a total daily dosage ofbetween about 6 and about 12 mg.

Galantamine may be administered to a patient in a total daily dosage ofbetween about 12 and 24 mg, e.g. 12 mg twice daily.

Dihydroergotoxin may be administered in the form of its methansulfonateto a patient in a total daily dosage of between about 4 mg and 10 mg,e.g. about 8 mg.

Nicergoline may be administered in the form of its tartrate byintramuscular injection to a patient in a total daily dosage of betweenabout 4 mg and 8 mg.

Piracetam may be administered to a patient in a total daily dosage ofbetween about 1200 and 5000 mg, e.g. 4800 mg/day.

Pentifyllin may be administered to a patient in a total daily dosage ofbetween about 400 and 800 mg.

Pyritinol may be administered in the form of its hydrochloride to apatient in a total daily dosage of about 600 mg.

Vinpocetin may be administered to a patient in a total daily dosage ofbetween about 10 and 15 mg.

Memantine may be administered to a patient in the form of memantinehydrochloride in a total daily dosage of about 20 mg.

In a further aspect, the present invention provides human monoclonalantibodies against Aβ1-42 induced by the CONSTRUCT, preferably Aβantibodies recognizing the N-terminus of Aβ1-42.

An efficient method to make human monoclonal antibodies from B cellsisolated from the blood of a human patient is described by ElisabettaTraggiai, Stephan Becker, Kanta Subbarao, Larissa Kolesnikova, YasushiUematsu, Maria Rita Gismondo, Brian R Murphy, Rino Rappuoli & AntonioLanzavecchia in Nature Medicine 10, 871-875 (2004), which publication isincluded by reference into the present specification.

EXAMPLES

In the following Examples 1 to 4, male and female patients are includedaged between 50 to 80 years (both inclusive), with mild to moderate ADas confirmed by a MMSE score of 16 to 26 (both inclusive), who areoutpatients with caregivers (living together or, if living alone, withdaily contact), who meet the DSM-IV criteria for dementia of theAlzheimer's type, and who satisfy the criteria for a clinical diagnosisof probable AD according to the National Institute of Neurological andCommunicative Disorders and Stroke (NINCDS-ADRDA). Each patientparticipates in a 4-week screening period (Day -28 to Day -1), abaseline period (pre-dose on Day 1 in week 0), three single dosetreatments under ambulatory conditions in weeks 0, 6 and 18 (Days 1, 43,127), ten additional ambulatory visits in bi- to four weekly intervalsin weeks 2, 4, 8, 12, 16, 20, 22, 26, 30, and 34 (i.e. on Study Days 15,29, 57, 85, 113, 141, 155, 183, 211 and 239), and two additionalambulatory visits in week 42 and 52 (i.e. on Study Days 295 and 365).Safety assessments include general physical examinations, neurologicalexaminations, 12-lead electrocardiograms (ECGs), vital signs, standardclinical laboratory evaluations (hematology, blood chemistry,urinalysis), special immunological laboratory evaluations in blood andcerebrospinal fluid (CSF), cerebral magnetic resonance imagings (MRIs),as well as adverse event and serious adverse event monitoring. Further,patients and caregivers are instructed (verbally and in writing) to lookfor any unexpected deterioration in health status.

Aβ-antibody response is measured by determination of the Aβ-antibodytiter (IgG and IgM) in serum and CSF using ELISA methods. The ex vivoAβ-antibody binding properties in serum and CSF is explored byimmunological methods on human and β-amyloid precursor protein (APP)transgenic mouse brain tissue. The VLP-antibody titer response in serumis measured to investigate the immune response to the carrier compoundin relation to the immune response to Aβ.

Exploratory pharmacodynamic assessments include the followingassessments: 1) determination of disease related markers in CSF (Aβpeptides and its isoforms, tau protein and its isoforms, phospho-tau)and plasma (Aβ peptides and isoforms); 2) volumetric MRIs, and 3)neuropsychological test battery, mini-mental state examination (MMSE),clinical dementia rating (CDR) and Alzheimer's Disease CooperativeStudy—Activities of Daily Living (ADCS-ADL), 4) Positron emissiontomography (PET) with ¹¹C-Pittsburgh Compound-B (¹¹C-PIB) which is anovel beta-amyloid selective tracer developed for in vivo detection ofβ-amyloid plaques in the brain and ¹⁸F-fluorodeoxyglucose (¹⁸FDG)

Responders are defined as those patients who show a significant increaseof Aβ-specific antibody titers above baseline and who show an antibodyisotype switch from IgM to IgG in serum at latest after the 3rdinjection. Aβ-specific antibody titers are defined as titers above lowerlimit of quantification (LLOQ) in a validated enzyme-linkedimmunosorbent assay (ELISA) assay detecting specific antibodies relativeto a standard serum as calibrator.

Example 1 A Single or Multi Center, Randomized, Double-blind,Placebo-controlled Study in Patients with Mild to Moderate Alzheimer'sDisease (AD) with Three Subcutaneous Injections of 25 μg of CONSTRUCT

A total of 30 patients is randomized to receive three s.c. injections ofthe CONSTRUCT or placebo. 24 patients receive the active drug CONSTRUCTand 6 patients receive placebo under double-blind conditions. Three s.c.injections of 25 μg CONSTRUCT or placebo are administered to eachpatient in weeks 0, 6 and 18.

Example 2 A Single or Multicenter, Randomized, Double-blind,Placebo-controlled Study in Patients with Mild to Moderate Alzheimer'sDisease (AD) with Three Subcutaneous Injections of 50 μg of CONSTRUCT

A total of 30 patients is randomized to receive three s.c. injections ofthe CONSTRUCT or placebo. 24 patients receive the active drug CONSTRUCTand 6 patients receive placebo under double-blind conditions. Three s.c.injections of 50 μg CONSTRUCT or placebo are administered to eachpatient in weeks 0, 6 and 18.

Example 3 A Single or Multicenter, Randomized, Double-blind,Placebo-controlled Study in Patients with Mild to Moderate Alzheimer'sDisease (AD) with Three Subcutaneous Injections of 100 μg of CONSTRUCT

A total of 30 patients is randomized to receive three s.c. injections ofthe CONSTRUCT or placebo. 24 patients receive the active drug CONSTRUCTand 6 patients receive placebo under double-blind conditions. Three s.c.injections of 100 μg CONSTRUCT or placebo are administered to eachpatient in weeks 0, 6 and 18.

Example 4 Determination of Antibody Titers in Serum

Blood samples are taken by direct venipuncture. A total of 10 mL venousblood is collected in plain barrier tubes. The sample are allowed toclot during 45 minutes at room temperature and then centrifuged for 10minutes at approximately 2500 g. Serum tubes are frozen within 60 minafter venipuncture and kept at <−70° C. pending analysis.

Example 5 A Single or Multicenter, Randomized, Double-blind,Placebo-controlled Study in Patients with Mild to Moderate Alzheimer'sDisease (AD) with Three Subcutaneous Injections of 150 μg of CONSTRUCT

A total of 30 patients is randomized to receive three s.c. injections ofthe CONSTRUCT or placebo. 24 patients receive the active drug CONSTRUCTand 6 patients receive placebo under double-blind conditions. Three s.c.injections of 150 μg CONSTRUCT or placebo are administered to eachpatient in weeks 0, 6 and 18.

Example 6 A Single or Multicenter, Randomized, Double-blind,Placebo-controlled Study in Patients with Mild to Moderate Alzheimer'sDisease (AD) with Three Subcutaneous Injections of 300 μg of CONSTRUCT

A total of 30 patients is randomized to receive three s.c. injections ofthe CONSTRUCT or placebo. 24 patients receive the active drug CONSTRUCTand 6 patients receive placebo under double-blind conditions. Three s.c.injections of 300 μg CONSTRUCT or placebo are administered to eachpatient in weeks 0, 6 and 18.

1. A method of reducing the severity or delaying onset of dementia inhuman patients comprising administering a construct consisting of avirus-like particle (VLP) structure chemically coupled to a fragment ofthe Aβ-1-42 peptide or its pharmaceutically acceptable salts,characterized in that the pharmaceutical composition is administeredsubcutaneously, and comprising administering 5 to 300 μg of theconstruct about every 4 to 8 weeks.
 2. The method according to claim 1wherein the dementia is dementia of the Alzheimer's type or vasculardementia with amyloid angiopathy.
 3. The method according to claim 1wherein the dementia is dementia associated with Parkinson's disease orLewy Body dementia.
 4. The method according to claim 1 wherein theconstruct consists of capsid proteins of a RNA bacteriophageself-assembled into a highly ordered VLP structure chemically coupledwith a bivalent linker to a fragment of the Aβ1-42 peptide.
 5. Themethod according to claim 4 wherein the capsid proteins are taken fromthe RNA bacteriophage Qβ.
 6. The method according to claim 4 wherein thefragment of the Aβ1-42 peptide is Aβ-1-6.
 7. The method according toclaim 1, wherein said construct is administered in an aqueous solutioncomprising between 0.25 and 0.75 mg/ml of said construct and phosphatebuffered saline.
 8. The method according to claim 1, wherein thepatients are at risk of developing Alzheimer's disease and furtherwherein the patients are selected from the group consisting of patientswith mild cognitive impairment, patients with genotypes known to beassociated with Alzheimer's Disease, patients with Trisomy 21 andpatients with surrogate markers indicating risk for Alzheimer's Disease.9. The method according to claim 8 wherein the patients with genotypesknown to be associated with Alzheimer's Disease comprise patients withthe ApoE4 genotype.
 10. The method according to claim 1 wherein theconstruct consisting of a VLP structure chemically coupled to a fragmentof the Aβ-1-42 peptide is administered at a total dose between about 5to 175 μg/4 to 8 weeks.
 11. The method according to claim 1 wherein theconstruct is administered about every 5 to 7 weeks.
 12. The methodaccording to claim 1 wherein the construct is administered about every 6weeks.